1/19. Retained digital foreign body after a pellet gun injury.A symptomatic foreign body embedded in the human body can be a frustrating problem for physician and patient alike. A unique case of a retained foreign object resulting from a pellet gun injury has been presented. Although the course of treatment in this case was uncomplicated, it is important to understand the complexities of the human body's response to foreign bodies.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/19. Whole blood transfusion for exsanguinating coagulopathy in a US field surgical hospital in postwar kosovo.An urgent blood drive in which active duty military field surgical hospital personnel volunteered to donate whole blood was conducted, and administration of warm, whole blood prevented the exsanguination of a normothermic coagulopathic patient who had received a massive transfusion. In austere care settings in which full blood banking capability may not be available, physicians should consider that exsanguinating hemorrhage can potentially be controlled surgically, but nonsurgical bleeding requires specific replacement therapy, and whole blood may be the best selection for repleting deficiencies of components that are otherwise unavailable.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/19. Economic, ethical, and outcome-based decisions regarding aggressive surgical management in patients with penetrating craniocerebral injury.Each year fatalities in the united states increase as a result of gunshot wounds to the head. This increase, coupled with the progressive limitation of medical and economic resources available at major trauma centers, has brought into question the concept that everything possible should be done to save the lives of victims, who have only a minimal and nonpredictable chance of having a good outcome. Thus, consideration must be given to the economics of treating cranial gunshot wounds and the relationship of this treatment to outcome. When a good outcome can be predicted, treatment should be aggressive. However, when a good outcome cannot be predicted, surgical intervention will have no effect and the potential costs of aggressive treatment must also be considered. Clearly, there are ethical dilemmas involved in withholding operative treatment from any individual, even if there is only a minimal chance of a reasonable neurologic recovery. A negotiation-based approach should be used in determining the medical and ethical benefits of aggressive management strategies. Unfortunately, the care of critically ill patients is inconsistent with this approach. In order to insure that the best decision is made, guidelines dictating when to surgically intervene must be made an essential part of the patient/health care provider negotiation--even in worst case scenarios. The combination of an extremely poor prognosis for these injuries, and economic constraints faced by government-run facilities today could suggest that some patients should be allowed to die. Thus, the physician must be a source of information for the families, providing support and becoming a decision-making partner regarding potential intervention. In each situation, a strict set of guidelines must be formulated to establish a moral foundation for the ultimate mutual decision.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/19. High-velocity bullet causing indirect trauma to the brain and symptomatic epilepsy.epilepsy is a frequent consequence after missile wounds of the brain. So far, no epilepsy cases with missile injury have been described in which epilepsy ensued without direct missile injury of the brain. During world war ii, in 1941, our patient, then a soldier in the German army, suffered a bullet injury to the head; the bullet entered the cranium at the base of the nose. The bullet penetrated the head below the base of the cranium and remained stuck subcutaneously left of the second cervical vertebra. In the field hospital the patient suffered from focal seizures. The fits ceased within a few years under medication. In 1990 the seizures returned, this time with secondary generalization. In our case, a 7.62-mm bullet from the Russian Tokarev military pistol was used, which is known to have the highest muzzle velocity of all handguns available (> 500 m per second). We suspect that the so-called hydrodynamic effect of this high-velocity bullet caused an indirect trauma to the brain. This case shows that symptomatic epilepsy can occur after a penetrating head injury, without direct injury to brain tissue by a missile. High-velocity missiles are increasingly used in armed conflicts around the world. In light of the case reported here, in which the initial epilepsy was exacerbated more than 50 years after the wounding event, physicians must consider this possibility when dealing with veterans presenting with seizures. This case also has implications for the payment of benefits and pensions.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/19. Trauma-induced coagulopathy and treatment in kosovo.The 67th Combat Support Hospital at Camp Bondsteel, kosovo, treated victims of trauma on an almost daily basis at the beginning of U.S. peacekeeping efforts in the region. Military health care personnel must respond quickly and efficiently when confronted with patient wounds resulting in massive blood losses. The limited medical resources of a field hospital often complicate efforts to treat the most severe injuries. One such case involved a young farmer riddled with gunshot wounds. Early volume/blood resuscitation before, during, and after surgery led to a massive blood coagulopathy. This case study describes the actions the physicians and nurses initiated to save this victim of violence. The subsequent discussion delineates methods to reduce intraoperative blood losses, blood transfusion alternatives, and technological advances in trauma resuscitation.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/19. A mouthful of trouble.The prehospital providers in this case performed a thorough and detailed assessment. They searched for and found a puncture wound in the posterior buccal region, and learned the patients was also hypoglycemic, with a history of diabetes, and insulin-dependent. It was not clear how the patient arrived at a hypoglycemic state, or if he had suffered a seizure. After the family arrived at the hospital and went to the patient's home, they determined the circumstances that caused this unusual presentation: The patient was the victim of a home-invasion robbery and had been shot in the mouth with a small-caliber weapon. The home invasion had taken place approximately 12 hours prior to the victim being found. The victim had been knocked unconscious by the force of the shot, although the bullet did not break any bones. He had not eaten prior to the shooting. Upon arrival at the ED, a small exit wound was noted behind the patient's left ear--hair and dried blood had obscured it from the prehospital providers. However, the providers did alert the ED physician to the buccal puncture wound, which enabled the physician to consider the possibility that the mouth wound was the result of a gunshot. Gunshot wounds are unpredictable in their damage patterns and effects on their victims. They might lead a patient to become hemodynamically unstable, but that was not the case here. Hemodynamic stability should not preclude the consideration of traumatic insult throughout your assessment. The initial presentation of this patient may have tempted EMS to pursue the suspicions stated by the neighbor at the scene (seizure), but a detailed assessment provided the information necessary to treat the man appropriately.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
7/19. Fatal spinal cord injury of the 20th president of the united states: day-by-day review of his clinical course, with comments.BACKGROUND: This article presents the medical history of the 20th president of the united states, James A. Garfield, with an emphasis on his spinal cord injury (SCI). Numerous references debate the care he received from the medical and surgical perspectives, but little has been written about the essential aspect of his gunshot wound-namely, the damage to his spinal cord. President Garfield was shot in the lumbar spine and was bedridden until he died 80 days following his injury. This article contrasts state-of-the-art care in 1881 to today's standards of care for SCI. METHOD: literature review. A record of daily reports of the president's condition was analyzed. Comparisons were made between the president's care and what is now available. FINDINGS: Although the president had access to the best physicians, the chronicle of his course underscores the deficiencies in basic medical care, the controversies concerning surgical intervention, and the problems inherent in the care of a prominent patient. Press releases did not overtly address spinal cord trauma and its complications so as to avoid conveying the president's degree of incapacity. Garfield's SCI was documented on autopsy. The bullet entered the 10th intercostal space, 3 1/2 inches to the right of the spinous processes, fracturing the 11th and 12th vertebrae and nicking the T1 2-L1 disc. The bullet then passed through the right side of the body of L1 and exited the vertebra anteriorly and to the left and lodged behind the pancreas, where it was found encased by a firm cyst. CONCLUSION: Deficiencies in general medical care and surgical technique at the time contributed to the president's demise. This case was marked by controversies that still are debated today-for example, whether the bullet should have been removed surgically. Examination of available evidence suggests that with today's advances in medical, surgical, and SCI medicine, a person with this type of injury would likely survive and be a candidate for rehabilitation.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/19. Ethical dilemmas in child and adolescent consultation psychiatry.Ethical issues in child and adolescent psychiatry consultation arise frequently but seldom are discussed in a public setting. This case of an adolescent victim of a surgical accident illustrates many aspects of consultation psychiatry. The consult question itself, of behavior management, is not unusual, although in this case the question is complicated by the sequelae of trauma, psychosocial chaos, and the staff's angry feelings toward the patient. In addition, potential surgical wrongdoing at the referring hospital brings up the more difficult ethical questions of the consultant's responsibilities, which must be to the patient and his family, as well as to the attending and referring physicians.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/19. Physical medicine and rehabilitation in the military: Operation Iraqi freedom.This article describes the role of a physical medicine and rehabilitation (physiatry) physician (physiatrist) as a general medical officer within a forward support battalion during the invasion and nation-building phases of Operation Iraqi freedom. Between March 10 and May 3, 2003 (invasion phase), 364 patients were evaluated. Thirty-two percent had musculoskeletal noncombat injuries, 9% had combat-related traumatic injuries, and the remaining 59% had nontrauma/nonmusculoskeletal conditions. Between May 4 and July 25, 2003 (nation-building phase), 1,387 patients were evaluated. Of these, 19% had musculoskeletal injuries, 1% had combat-related traumatic injuries, and the remaining 80% had nontrauma/nonmusculoskeletal conditions. During this nation-building phase, the musculoskeletal workload seen at the division-level combat support hospital was 4 times the workload seen in the forward support battalion. This experience underscores the role of physiatry in wartime casualty management and profiles the combat support hospital as the most suitable place for the physiatrist during wartime. Interventions focused on acute management and rehabilitation counseling for all musculoskeletal injuries, as well as consultation services to the combat support hospital and local civilian hospitals for the evaluation of complex neuromusculoskeletal trauma cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/19. Difficult airway management.airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult. The most important part of success in the management of a difficult airway is preparation. When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response. The following article will review the principles of airway management with an emphasis upon preparation, strategies for preventing or avoiding difficulties, and recommended technical details that hopefully will encourage the reader to be more prepared and technically skillful in practice.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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